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Surgery for nasal cavity and paranasal sinus cancers

For most nasal cavity or paranasal sinus cancers, surgery to remove the cancer (and some of the surrounding bone or other nearby tissues) is an essential part of treatment. If the cancer has spread to the lymph nodes in the neck, the surgeon may also remove lymph nodes with an operation called a neck dissection. Often, surgery is combined with other treatments such as radiation therapy to get the best result.

The area around the nasal cavity and paranasal sinuses has many important nerves, blood vessels, and other structures. The brain, eyes, mouth, and carotid arteries (arteries that supply blood to the brain) are also close by, making surgical planning and surgery itself difficult. The surgeon must also take into account how the face will look and function after surgery.

The goal of surgery in these areas is to remove the entire tumor and a small amount of normal tissue around it while keeping appearance and function (such as breathing, speech, chewing, and swallowing) as normal as possible.

Unfortunately, these cancers often involve the eye or orbit (the bone and tissue surrounding the eye) by the time they are noticed or cause symptoms. Most of the time the eye can be saved, but sometimesthe entire orbit and eye may need to be removed to give the best chance for cure.

Depending on the extent of the operation needed, your appearance may change as a result of surgery. This can range from a simple scar on the side of the nose to more extensive changes if nerves, parts of bones, or other structures need to be removed. It’s important to talk with your doctor before the surgery about what these changes might be to help prepare you for them. He or she can also give you an idea about what options might be available afterward, such as reconstructive surgery.

Because of the complex nature of these operations and the fact that these cancers are not common, it’s very important to have a surgeon who has experience treating these cancers.

When cancers are removed, the surgeon also tries to take out a rim of surrounding normal tissue. After a cancer surgery, the tissue that is removed will be looked at under the microscope to see if the edges contain cancer cells. If the edges don’t contain cancer cells, the cancer is said to have been removed with “negative” or “clear” margins. Negative margins mean that it is less likely that any cancer was left behind. If the edges do contain cancer cells, the margins are said to be “positive.” Positive margins make it more likely that some cancer was left behind. Often this means further treatment, such as more surgery or radiation.

Nasal cavity cancers

Nasal cavity cancers are often removed by a procedure called wide local excision. This means removing the tumor plus an area of normal tissue surrounding it. The goal is to remove enough tissue so that no cancer cells remain.

If the tumor is in the middle dividing wall of the nasal cavity (the nasal septum), sometimes the entire septum or a large portion of it will be removed.

If the tumor is in the lateral (side) wall of the nasal cavity, often this wall must be removed by a procedure called a medial maxillectomy. For this operation, the surgeon will usually cut through the skin along the side or edge of the nose and fold the external nose toward the opposite side to see and work on the tumor. Then the side of the nasal cavity can be removed by cutting the bone and soft tissue as needed. Sometimes, if the cancer is in a certain spot, the surgeon can reach the tumor by cutting under the upper lip instead. This approach has the advantage of avoiding any skin incisions.Ask your head and neck surgeon about which approach or incision you may need.

If the cancer has reached the skin or deeply invades the tissue of the external nose, part (or all) of the nose may need to be removed. There are many ways to rebuild a nose using tissue from the face or other areas. Or a cosmetic prosthesis (made of artificial materials) may be used to make a new nose.

Paranasal sinus cancers

Operations for paranasal sinus tumors vary, depending on its specific type, location, size, and growth into other structures.

If the tumor is very small and/or benign and is only in the ethmoid sinuses, an external ethmoidectomy may be done. The surgeon performing this operation will cut through the skin on the upper side of the nose next to the upper eyelid. Bone on the inner side of the orbit (eye socket) and nose will be removed to reach tumors inside the ethmoid sinuses.

If the tumor also has grown into the maxillary sinus, a maxillectomy may be done. The type of maxillectomy depends on where the tumor is and whether it also has grown into nearby tissues. The surgeon may make an incision along the side of the nose from the eyebrow or upper eyelid down to or through the upper lip. Or the incision may be made under the upper lip as discussed above. The bones around the maxillary sinus are cut so that the entire tumor and some surrounding tissue can be removed in one piece. This operation may remove bone from the hard palate (the roof of the mouth), upper teeth on one side of the mouth, part or all of the orbit (eye socket), part of the cheekbone, and/or the bony part of the upper nose.

If the cancer is in the ethmoid sinuses, frontal sinuses, and/or the sphenoid sinuses, an operation called a craniofacial resection may be done. This operation is similar to a maxillectomy except that the surgeon may also remove upper parts of the eye socket and the front of the skull base. This is an extensive operation that is done by a surgical team that usually includes an otolaryngologist (head and neck surgeon) and a neurosurgeon (a surgeon who operations on the brain, spinal cord, and other nerves).

Endoscopic surgery

In this type of surgery, the surgeon uses an endoscope (a thin, flexible lighted tube inserted into the nose to reach the nasal cavity or sinus) to see and remove the tumor. That way, the surgeon does not have to cut through bone to open up the whole cavity. This reduces the actual amount of normal tissue destroyed. In general, recovering from this type of surgery takes less time.

Endoscopic surgery is most often used for smaller tumors. For larger tumors, it may be used to help try to control the tumor in people who are not healthy enough for a bigger operation. Usually it is combined with radiation treatment.

Endoscopic approaches to remove nasal and sinus cancers are being used more commonly as an increasing number of surgeons are trained in these techniques. These approaches might be less invasive but are best performed by teams of experienced surgeons at specialized centers. Some medical centers (and surgeons) have more experience than others with endoscopic surgery for nasal and sinus cancers. If you are considering endoscopic surgery as a part of your treatment, be sure to ask about your surgeon’s training and experience, which are key to successful endoscopic surgery.

Removing lymph nodes

Cancers of the nasal cavity or paranasal sinuses sometimes spread to the lymph nodes in the neck. Depending on the stage and location of the cancer, these lymph nodes may need to be removed in an operation called a neck dissection.

There are several types of neck dissection procedures. Their goals are to remove lymph nodes proven or likely to contain cancer. The amount of tissue removed depends on the primary cancer’s size and the extent of spread to lymph nodes.

A partial or selective neck dissection removes only a few lymph nodes.

A modified radical neck dissection removes most lymph nodes on one side of the neck between the jawbone and collarbone, as well as some muscle and nerve tissue.

A radical neck dissection removes nearly all nodes on one side of the neck as well as even more muscles, nerves, and veins.

The most common side effects of any neck dissection are numbness of the ear, weakness in raising the arm above the head, and weakness of the lower lip. These occur when nerves that reach these areas are damaged. After a selective neck dissection, the weakness of the arm and lower lip usually go away after a few months. But if a nerve is removed as part of a radical neck dissection or because of tumor spread then the weakness will be permanent. After any type of neck dissection, physical therapists can teach the patient exercises to improve neck and shoulder movement.